CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 12355 38569.75000 1425760.3000 36.9658
Subtotal (Total Children Is Unduplicated) 12355 38569.75000 1425760.3000 36.9658
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 28.000000 2100.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 56 99.000000 7425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 50 82.000000 6150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 28 52.000000 3900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 18.000000 1350.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 20 37.000000 2775.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 52.500000 2913.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 82 139.500000 7742.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 353 665.000000 49875.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1026 1798.000000 134752.5000 74.9458
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 94 167.000000 12525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 658 1074.500000 80509.5000 74.9274
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 129 241.500000 18112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 381 677.000000 50677.5000 74.8560
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 450 855.000000 47452.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1501 2594.500000 143994.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 168 314.000000 23550.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 413 731.500000 54667.5000 74.7334
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.000000 1437.6000 71.8800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 7.000000 357.3500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 11 10.000000 510.5000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 20 20.500000 1046.5250 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 27 28.000000 1429.4000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TLGT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 19 19.000000 950.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 15 13.500000 689.1750 51.0500
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 41 43.000000 2195.1500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 14.000000 714.7000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 6 6.000000 267.3000 44.5500
Subtotal (Total Children Is Unduplicated) 3043 9902.500000 665488.6700 67.2041
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.000000 214.3200 71.4400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4059 25481.25000 1273987.5000 49.9971
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1460 6366.250000 318207.5000 49.9835
OCCT-97530-OT SESSION BY LICENSED OT 381 1652.250000 117972.4200 71.4011
OCCT-97530GT-OT SESSION BY LICENSED OT 37 97.500000 6965.4000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 174 903.750000 51590.1000 57.0845
OCCT-97530HMGT-OT SESSION BY OT ASST 12 12.500000 715.0000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 95 328.750000 23485.9000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 119 395.500000 28254.5200 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 4 20.000000 1144.0000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 28 133.500000 7636.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 426 1818.500000 129913.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 40 132.250000 9447.9400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 89 474.750000 27136.7100 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 10.500000 600.1800 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 114 393.250000 28093.7800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 82 193.250000 13805.7800 71.4400
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 2
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110TLHM-PT SESSION BY PT ASST 10 56.250000 3215.2500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 551 2801.549972 200085.1700 71.4195
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 77 285.000000 20299.2400 71.2254
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 11.500000 657.8000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 218 824.000000 58780.7600 71.3359
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 127 461.750000 32987.4200 71.4400
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 9.000000 124.9200 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 6528 42872.79997 2355484.1300 54.9412
-----------------------------------------------------------------------------------------------------------------------
Total 91345.049972 4446733.1000 48.6806
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 13931
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 144 157.500000 8339.0800 0.0000
S 635 576.000000 31914.7300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.750000 64.7500 0.0000
Other 110 173.750000 11029.0000 0.0000
---------------------------------------------------------
Total 891 909.000000 51347.5600 0.0000
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1 0.250000 9.2500 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1602 1122.000000 48223.5000 0.0000
---------------------------------------------------------
Total 1603 1122.250000 48232.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.250000 154.6900 0.0000
U 0 0.000000 0.0000 0.0000
B 1976 1732.250000 86144.0200 0.0000
P 81 76.250000 3988.3400 3988.3400
D 5 6.250000 373.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
23 23.000000 1422.3800 0.0000
Other 112 125.000000 5118.0000 0.0000
---------------------------------------------------------
Total 2201 1966.000000 97200.9300 3988.3400
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 17.000000 1044.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2921 4558.750000 181516.5700 0.0000
P 662 1154.250000 42752.2200 42716.5000
D 34 42.000000 1554.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1604 5350.500000 270729.9700 0.0000
T 0 0.000000 0.0000 0.0000
307 387.000000 23323.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5541 11509.500000 520920.2100 42716.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 58 40.250000 1489.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2369 1557.250000 57618.2500 16372.5000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 8.250000 305.2500 0.0000
Other 69 52.000000 1924.0000 0.0000
---------------------------------------------------------
Total 2512 1657.750000 61336.7500 16372.5000
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10565 9661.000000 468688.7900 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 10567 9662.000000 468725.7900 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 93 84.750000 3135.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 993 966.750000 45570.5000 0.0000
P 1549 1374.250000 58848.5000 58716.9000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.250000 9.2500 0.0000
9 5.750000 212.7500 0.0000
Other 50 24.500000 906.5000 0.0000
---------------------------------------------------------
Total 2696 2456.500000 108692.5000 58716.9000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1094 1172.000000 47238.7600 37.0000
P 3350 3466.750000 138566.8800 138566.5050
D 11 11.000000 550.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 9 7.750000 364.7500 729.5000
1847 6249.000000 348058.4000 0.0000
Other 228 410.500000 27019.5000 0.0000
---------------------------------------------------------
Total 6549 11325.500000 562112.7900 139333.0050
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 66 72.500000 3365.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8677 7560.500000 318240.7500 0.0000
P 71 63.250000 2377.2500 16.6500
D 19 17.500000 723.5000 0.0000
S 18 42.500000 2435.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3640 10373.750000 592281.6300 0.0000
Other 1206 966.000000 38628.5000 0.0000
---------------------------------------------------------
Total 13697 19096.000000 958053.0100 16.6500
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
322 1032.750000 60453.8300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 322 1032.750000 60453.8300 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 43.000000 2416.5200 0.0000
U 0 0.000000 0.0000 0.0000
B 576 633.750000 31148.8300 37.0000
P 1603 1695.250000 76555.1200 76317.0800
D 0 0.000000 0.0000 0.0000
S 33 39.750000 1706.6300 59.2500
H 2 1.250000 59.2500 9.2500
T 2 4.000000 200.0000 0.0000
714 1332.750000 79784.9800 0.0000
Other 4 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 2976 3752.500000 191973.0800 76422.5800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 36 35.000000 1415.8800 0.0000
U 0 0.000000 0.0000 0.0000
B 1668 1578.500000 79670.1100 9.2500
P 743 728.500000 34954.0200 34954.0600
D 28 26.750000 1893.8000 0.0000
S 96 71.250000 3188.4500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2242 2193.500000 111668.7500 0.0000
Other 324 242.750000 11218.0600 0.0000
---------------------------------------------------------
Total 5137 4876.250000 244009.0700 34963.3100
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 121 168.250000 10390.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2823 2491.750000 111546.1500 0.0000
P 925 905.000000 42533.0400 42533.0400
D 8 6.750000 413.3400 0.0000
S 50 54.500000 3918.9800 0.0000
H 1 1.000000 71.4400 0.0000
T 0 0.000000 0.0000 0.0000
3619 3592.750000 176828.9300 0.0000
Other 148 110.250000 4677.6500 155.6900
---------------------------------------------------------
Total 7695 7330.250000 350379.5300 42688.7300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3119 2997.250000 132240.1500 0.0000
P 2 2.250000 159.2500 159.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3377 3526.549972 214719.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6498 6526.049972 347118.7000 159.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 962 1516.750000 63268.2500 0.0000
P 1880 2572.500000 110943.0000 119185.7200
D 0 0.000000 0.0000 0.0000
S 1 1.500000 83.2500 83.2500
H 0 0.000000 0.0000 0.0000
T 7 8.000000 410.0000 79.9500
1140 4020.000000 201324.1000 200788.5500
Other 2 4.000000 148.0000 0.0000
---------------------------------------------------------
Total 3992 8122.750000 376176.6000 320137.4700